SGEM#280: This Old Heart of Mine and Troponin Testing

Date: January 16th, 2020 Reference: Troponin Testing and Coronary Syndrome in Geriatric Patients With Nonspecific Complaints: Are We Overtesting? AEM January 2020 Guest Skeptics: Dr. James VandenBerg: James has a master’s degree in clinical investigation from Washington University in St. Louis, and is currently the Chief Resident at Detroit Receiving Hospital. Dr. Andrew Huang: Andy is the Chief Resident at Sinai-Grace Hospital. Case: As the resident, you have just finished seeing a 78-year-old male who has been brought in by his family over the holidays. The triage nurse has put the reason for the visit as “multiple complaints”. Despite spending 30 minutes in the room, you still are not sure exactly why the patient is here. Your attending says that if you take a good geriatric history that you can always determine what’s going on. However, 15 minutes later your attending leaves the room defeated. The patient’s complaints are just so nonspecific. The attending ends up ordering the “geriatrogram” – ticking off every blood test on the form, including the troponin. You turn to the attending and ask, “do you really think this could be acute coronary syndrome (ACS)?” Background: Patients 65 years and older account for about 15% of emergency department visits in the United States. Their presentations are often complicated as they present with nonspecific symptoms, and there is often obscuring co-morbid conditions, polypharmacy, and cognitive/functional impairment. Nonspecific symptoms in the elderly usually yield a broad differential and there are no recommended diagnostic algorithms, leading to extensive testing. ACS is usually amongst this differential, as cardiovascular disease is a leading cause of morbidity and mortality in this population. Additionally, the elderly population with ACS more commonly presents without chest pain compared to younger patients (up to 20% of elderly patients with MI present with “weakness” as part of their chief complaint). While cardiovascular disease is the leading cause of mortality and morbidity in the elderly, the frequency of ACS amongst this population presenting with nonspecific symptoms is unknown. Clinical Question: What is the frequency of ACS in elderly patients presenting to the ED with nonspecific complaints, and what is the utility of troponin testing in this population? Reference: Wang et al. Troponin Testing and Coronary Syndrome in Geriatric Patients With Nonspecific Complaints: Are We Overtesting? AEM January 2020 Population: Patients aged 65 years and older presenting to the emergency department with nonspecific chief complaints who underwent troponin testing. “Nonspecific” was designed a priori as including weak or weakness, dizzy or dizziness, fatigue, lethargy, altered mental status, light-headedness, medical problem, examination requested, failure to thrive, or “multiple complaints.” Exclusions: If they had a focal chief complaint (ex. focal pain, injury complaint, shortness of breath, vomiting, diaphoresis, syncope, fever, cough, focal neurologic deficit)or fever of at least 38C at triage. Investigation: Troponin testing Comparison: None Outcomes: There were multiple outcomes of interest: The proportion of patients with nonspecific complaints who underwent troponin testing. The proportion of such patients who had elevated troponin. The proportion of patients with ACS at the index visit or within 30 days. The utility of troponin testing to diagnose or exclude ACS. The frequency of other causes of troponin elevation in this population. Dr. Alfred Wang This is a LIVE episode of an SGEMHOP which means we have the lead author on the show.  Dr. Alfred Wang is an emergency medicine physician at Indiana University in Indianapolis, IN. With the help from a dedicated team of physician-peers and mentor, Dr. Wang was able to complete this research project.